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First Visit - General Information
If you are pregnant, which option are you considering?
*
Abortion
Adoption
Parenting
Undecided
Date
*
+
First Name
*
Last Name
*
MI
Spouse Name
Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip/Postal
*
Cell Phone
*
Home Phone
Work Phone
Fax:
Is it okay for us to contact you?
*
Email
Mail
No
Phone
Text
Do you want us to block caller ID when we call your home?
Yes
No
Do you want us to block caller ID when we call your cell?
Yes
No
Email
Personal Information
Birth Date
*
+
Primary Language
Ethnicity
African American
Alaska Native
Asian
Caucasian
East Indian
Hispanic
multi-Racial
Native American
Pacific Islander
Other
Other
Occupation/School
How did you hear about us?
800#/Hot Line
Church
Girlfriend
Walk-in
Court
Health Dept
Previous Client
Web Site
Doctor's office
Internet
School
Friend/Relative
Mail
Teacher
WIC
Other
Other
What outside help are you receiving?
Boyfriend
Family
Girlfriend
Insurance
Church
Food Stamps
HUGS
Medicaid
WIC
Friends
Husband
SSI
Other
Other
What are your living arrangements?
Alone
Fiancé
Girlfriend
Homeless
Shelter
Father
Boyfriend
Foster Parents
Grandparents
Mother
Parents
Spouse
Friend
Other
Other
Spiritual Information
Are you a Christian?
Yes
No
Religion
Atheist
Hindu
Native American
Buddhist
Jehovah's Witness
Jewish
Christian (Amish)
Mormon
Christian (Catholic)
Muslim / Islam
WICCA
Other
Other
What is your current relationship with God?
Close
Okay
Desire to be better
None
Have you been baptizied?
Yes
No
If yes, when?
+
Demographic Information
Marital Status
Divorced
Remarried
Engaged
Separated
Living Together
Single
Married
Widowed
Never Married
Never Married
Student Status
Middle School or Jr. High
High School
College or University
Trade School/Other
Not Student
Not Student
Education (highest level completed)
Graduated College
Graduate School
Some Graduate School
Trade School
Some College
High School or GED
Less than High School
Less than High School
Partner Information
Potential Father's Name
Potential Father's Age
If the test is positive, will he be involved?
Yes
No
Unsure
Not applicable
Are you looking for a future with him?
Yes
No
Unsure
Not applicable
Does he know that you might be pregnant?
Yes
No
Unsure
Not applicable
What is your relationship with the potential father?
Boyfriend
Fiancé
Friend
Husband
Other
Children Information
Child 1 Information:
First Name
Last Name
Date of birth
+
Sex
Male
Female
Weight at birth (lbs/oz)
Is this child deceased?
Yes
No
Child 2
Information:
First Name
Last Name
Date of birth
+
Sex
Male
Female
Weight at birth (lbs/oz)
Is this child deceased?
Yes
No
Child 3
Information:
First Name
Last Name
Date of birth
+
Sex
Male
Female
Weight at birth (lbs/oz)
Is this child deceased?
Yes
No
Child 4
Information:
First Name
Last Name
Date of birth
+
Sex
Male
Female
Weight at birth (lbs/oz)
Is this child deceased?
Yes
No
Child 5
Information:
First Name
Last Name
Date of birth
+
Sex
Male
Female
Weight at birth (lbs/oz)
Is this child deceased?
Yes
No
Visit Information
Have you ever been to our pregnancy center before?
Yes
No
If yes, when?
+
Under the same name as input above?
Yes
No
If under a different name, what name did you use to see us before?
What is the primary reason for this visit?
*
Appointment
Baby/Maternity Supplies
Individual Education
Post-Abortion help
Pregnancy Test
Ultrasound
Other
Other
Who accompanied you on this visit?
Boyfriend
Father
Friend
Girlfriend (male clients)
Grandfather
Grandmother
Husband
Mother
Wife (male clients)
No one
Fiancé
Other
Other